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'Distracted' doctor failed in boy's care

Isabel Hayes

An anaesthetist who was so "distracted" by the appearance of a toddler that he didn't properly assess him before he died has been referred to the medical complaints body.

Dr George Waters' failure to properly assess two-year-old Leonard Crowe at his dental surgery at Broken Hill Base Hospital (BHBH) on July 11, 2008, was "a fundamental failure of judgment", Deputy State Coroner Brian MacMahon said on Friday.

Leonard never regained consciousness after he had 13 decayed teeth removed and six others repaired under general anaesthetic at the hospital.

The little boy had numerous medical issues, including club feet, a retreating jaw and a breathing problem known as apnoea.

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An autopsy showed he had a respiratory tract infection on the day of surgery.

Dr Waters, who was Leonard's principal anaesthetist for the surgery, admitted during the inquest that he failed to properly assess Leonard prior to the surgery and the standard of care provided was "less than adequate".

Dr Waters was unaware of Leonard's medical history - which included suffering from partial lung collapse while under general anaesthetic in 2007 - and did not read the child's file.

Despite observing Leonard's facial features which indicated anesthesia would probably be more complicated, Dr Waters didn't carry out a medical examination and did not speak to Leonard or his mother, Tina Crowe.

"His examination was in fact no more than a cursory observation from the distance," Mr MacMahon said in his findings.

When asked why he did not properly assess Leonard, "All (Dr Waters) could come up with was that he became `distracted' by Leonard's physical appearance", the coroner said.

The coroner found Leonard died from cardiac arrest due to lack of oxygen arising from airway obstruction following anaesthesia.

He said the surgery should not have been carried out at the BHBH, particularly as it was not urgent and Leonard was due to travel to Adelaide Women and Children's Hospital (AWCH) for other surgery.

"Had he been referred to AWCH for this (dental) surgery, Leonard may well be alive today," Mr MacMahon said.

The inquest heard Leonard's pre-admission report, carried out by Dr Moe Zaw, was also inadequate and failed to take his medical file into account.

The coroner said he was concerned about Dr Waters' fitness to continue practising as an anaesthetist, despite his professed intention of leaving the job.

"Such failure may be a tragic one-off or it may be indicative of a general failure of practice or judgement on his part," Mr MacMahon said, referring Dr Waters to the Health Care Complaints Commission (HCCC).

The coroner commended the hospital for changing its procedures to avoid similar failures in future.

"It is good to see that changes have been made at BHBH that, hopefully, will ensure that such a tragedy does not happen in the future," Mr MacMahon said.

Leonard's family members, who told the inquest his death had "destroyed" them, were not in court for the findings.